Insights from Jaya Aysola, MD, MPH, DTMH; and John C. Lin, MD candidate, on clinical workflows, social needs screening, and policy levers.
Jaya Aysola, MD, MPH, DTMH
Founder and Executive Director of Penn Medicine Center for Health Equity Advancement
Image credits: UPenn
John C. Lin
MD Candidate, University of Pennsylvania, Truman Scholar
Image credits: LinkedIn
US adults experiencing food insecurity had a 78% higher likelihood of current long COVID and a 34% lower likelihood of recovery after prior long COVID, with lower risk observed among those participating in the Supplemental Nutrition Assistance Program (SNAP) and those who were employed. These estimates come from an analysis of 21,631 respondents in the 2022-2023 National Health Interview Survey who reported prior COVID-19 and answered questions on food insecurity and long COVID.
Current long COVID was defined as symptoms lasting at least 3 months after infection and present at the time of interview, whereas recovery meant a history of long COVID without current symptoms. Food insecurity was measured using the validated 10-item National Center for Health Statistics scale. In adjusted models, food insecurity was associated with higher odds of current long COVID (OR, 1.73; 95% CI, 1.39-2.15) and lower odds of recovery (OR, 0.70; 95% CI, 0.54-0.92). Weighted prevalence of current long COVID was 15% among those with food insecurity vs 7% among those without, and interaction tests suggested mitigation with SNAP participation and employment (P for interaction = .04 for each).
These findings position food insecurity as a potentially modifiable risk factor that may influence both development and persistence of long COVID and point to policy levers such as expanding SNAP eligibility, simplifying enrollment, and increasing program awareness. To explore mechanisms, clinical steps, and policy implications, we spoke with study investigators Jaya Aysola, MD, MPH, DTMH, founder and executive director of Penn Medicine Center for Health Equity Advancement, and John C. Lin, MD candidate at the University of Pennsylvania and Truman Scholar.
Aysola said, “The important thing to start out with is that we cannot definitively say, 'So the challenges with association studies [are] that you can't really infer causality or directionality,' right? So you don't know which came first, sort of like the chicken and the egg.”
She set up what we know from practice: “A few things we do know that we do see, just generally, [are] that delayed care due to financial hardship or unemployment can lead to people making tough choices around having to choose food over access to care, for example, which could help with prevention and protection against getting COVID-19 and then subsequently being treated for COVID-19 and perhaps being prevented from getting long COVID,” Aysola said.
Building on possible biological pathways, Aysola added, “We also know that reduced consumption of healthy nutrient-dense food does impact other chronic conditions, and whether it could impact the way one is predisposed to getting long COVID is also an unanswered question but a potential mechanism by [which] this could happen. The way food insecurity manifests in the US is not actually a lack of access to food at large but more a lack of access to nutrient-dense food, and those foods are far more important for chronic diseases. And even in this case, potentially, one would hypothesize, reducing your chances of recovering from COVID-19.”
She also noted the possibility that the relationship runs in the other direction: “The other option is if the direction goes the other way around. So say long COVID may increase your risk of food insecurity by impairing people's ability to work, creating financial hardship, etc. So because we can't really say which direction [it] is going, there are a couple of hypotheses that we can put forward in both directions to explain this link.”
Aysola turned to what clinicians can do now and how policy can reinforce those efforts. Aysola said, “The first thing when I think about what clinicians can do, they could think about, 'What can I do in my practice? And then what can we do from a policy perspective?' But in terms of practice, one of the easiest and first things we need to start to think about is how we can routinely and systematically screen for food insecurity, and not just screen for it or assess it, but actually code it to capture the extent of the issue in our practice.”
She emphasized that documentation is foundational to change. “There are Z codes that people can use to capture when there's food insecurity, that they're assessing, that there's a positive assessment in their practice. They can actually code for that, and that has 2 functions. One is that it captures this extent of the problem. It also sets the groundwork to be able to lobby for what we've done for other things in public health, to lobby for billables around that. For example, smoking cessation, discussion, screen. Screening for smoking started out as merely Z codes, but over time, it became something that you could actually bill for.”
She connected this to building sustainable workflows. “So you could bake into your practice that you've screened for smoking and then you've spent x number of minutes discussing smoking prevention and smoking cessation strategies. I think similarly, with social needs and food insecurity specifically, we can march down a similar path where we're starting to make those assessments in a clinical care setting like a practice and beginning to code for it with existing codes and then work our way to beginning to be able to bill for something like that. In order to bill for solutions and fund solutions in a practice-based setting, I think the other thing the clinician does in real time. And when I say bill, I mean bill the insurance companies, not, obviously, the patients.”
She then outlined how practices can pair screening with immediate help. “What I think we can also do as clinicians in the practice-based setting is advocate for resources to assist with positive screens or positive assessments, so either practice-based resources or community-based resources. I think [about] what this shows us from SNAP participation and employment status. So I think from this that SNAP is an absolute benefit. Enrollment is key to all of this, right? And so from a policy standpoint and a practice standpoint, from a practice standpoint, embedding and thinking about how case managers or practice staff are needed to help patients who are eligible for SNAP get enrolled in SNAP are a part of that practice-based resourcing that needs to be done.”
Finally, she called for advocacy through professional societies to widen access. “From a policy standpoint, there needs to be more pressure from clinicians using their national societies to advocate for the importance of enhanced eligibility for SNAP programs. Because what we see, and this is important, is irrespective of employment status. So employed individuals without SNAP benefits who have food insecurity are also more predisposed and have a higher chance of both getting COVID-19 and then not recovering from it. So there's an important [need] to expand benefit enrollment as well, irrespective of employment status and irrespective of the federal poverty line that patients are in, whether they're in higher-income brackets or lower-income brackets.”
Lin underscored the biological and social mechanisms that can tie food insecurity to persistent symptoms. “Food insecurity often leads to poor nutrition, chronic stress, and limited health care access, all of which may impair immune recovery and worsen lingering symptoms. These biological and social stressors can amplify vulnerability to long COVID. It's hard to recover when your body doesn't have the right fuel.”
He outlined concrete steps for frontline teams and public health agencies. “Clinicians can screen for food insecurity just as they do for vital signs and connect patients to SNAP or local food resources. Public health programs can normalize food assistance as part of chronic disease management, not just emergency aid. Nutrition is an important medicine too.”
Aysola also pointed to income-related nuances that strengthen the policy case. Aysola said, “I think one of the findings that our study showed was that if you're at the highest-income brackets, like greater- or middle-income brackets, greater than 200% of federal poverty line, etc, that you're still more likely if you [have] food insecurity to [have] a much greater risk of getting COVID-19 and not recovering from it.”
She contrasted this with lower-income groups and the potential role of benefits. “And I think what that shows you is that sometimes you're at greater risk than those at [a] lower-income bracket, and SNAP, I think, explains that away in the sense that right now, our federal funding, unfortunately, currently, and it's going to get worse before it gets better.”
Adults with food insecurity had 78% higher odds of current long COVID and were twice as likely to report symptoms as food secure peers.
Recovery after prior long COVID was 34% less likely with food insecurity, underscoring nutrition and access to care as modifiable factors.
Screening for food insecurity and connecting patients to SNAP and local resources can help clinicians lower risk and improve outcomes.
She then connected these findings to eligibility rules and how they might evolve. “Our federal funding has a very rigid requirement for staff benefits that one could really push to expand eligibility criteria. And maybe not; it doesn't have to be just by income. It could be [to] expand eligibility criteria by certain conditions or [for] folks who are more predisposed, perhaps, to get long COVID. Beyond this, who is more at risk, to have caveats around that. Maybe it's age-based eligibility criteria, etc.”
Finally, Aysola underscored the urgency of policy action amid rising need. “But regardless, right now, we're in a landscape where I'm talking about this, where investments in those programs are actually decreasing or potentially decreasing in another year or so, at a time where food insecurity is increasing in the population at large because of increased costs of groceries, etc. So you have a perfect storm right now by which to wade through with existing eligibility criteria, and so there's a lot of policy work needed to be done to address this issue, which I think is going to be multifactorial, with a lot of people on board, from public health practitioners to folks who are really pushing for how do you invest in food as medicine to individuals like clinicians who are maybe leveraging their societal or national societies, medical societies, to act as that advocate arm and make that connection of food to help.”
Lin added a clear policy prescription. “Policies that expand SNAP eligibility, simplify enrollment, and raise awareness should be top priorities. Fighting long COVID starts with fighting food insecurity.”
Taken together, the investigators’ findings and perspectives point to a practical path forward: integrate routine food insecurity screening into clinical workflows, connect patients to food benefits and local resources, and leverage professional societies to advocate for expanded SNAP eligibility and simpler enrollment so that preventing and treating long COVID includes addressing the social conditions that shape recovery.
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